Earlier chapters addressed gaps and barriers in specific sectors of home health care (e.g., workforce, payment, models of care, technology). However, beyond these challenges, home health care sits within a larger system of care that needs to be considered. In one panel at the workshop, three speakers spoke about different connections that are needed to integrate home health care into the broader health care environment: connecting to the overall health care system, connecting to social services, and connecting data.
The Brookings Institution
Changes in the broader health ecosystem affect home health significantly, said Gage, especially as organizations focus on the triple aim of the Patient Protection and Affordable Care Act of 2010 (ACA)1: improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care. “These initiatives were always under way, but nobody had pulled them together into one related effort.”
Gage reviewed a number of significant changes in the health care envi-
1 Patient Protection and Affordable Care Act of 2010, Public Law 111-148, 111th Cong., 2nd sess. (March 23, 2010).
ronment that are in progress. She noted that the U.S. Congress has required that all Medicare-funded services have quality reporting programs in place, whereas in the past, only hospitals and nursing facilities had them. Innovative payment methods are focusing not only on the costs of care but also on outcomes, thus focusing the conversation—and payment—on value and not just ongoing payment for additional services. Shared savings from the achievement of quality goals are available to several categories of providers, and incentives to coordinate care are in place, she said. Finally, she said, accountable care organizations (ACOs) must integrate care across the health care system because they are financially responsible for patient outcomes.
Gage noted that additional new programs target specific populations, programs, and services, such as people who are eligible for both Medicare and Medicaid, programs of long-term services and supports (LTSS), and Medicaid efforts to serve more recipients in the community (rather than in nursing homes). The high-cost Medicare population and the population receiving LTSS tend to be the same people: those living in the community who have many medical and social support needs. “That’s where home health really comes into the picture,” she said. In addition, innovations, such as carve-out initiatives for high-risk populations, are occurring in the private payer sector.
Role of Home Health in the Medicare Program
Home health can play a number of central roles in this changing marketplace. Gage said that it can—and often does—provide the desired coordination across providers, whether it occurs at times of transition (e.g., from hospital to home) or between medical and social supports, and for patients and family caregivers it is often an educational resource describing care options and resources. Gage provided some data (MedPAC, 2013) about the people served in the Medicare home health program, showing that
- Sixty-six percent of patients enter a home health program from the community and not the hospital.
- Patients admitted from the community have an average of 3.8 chronic conditions, and 29 percent have Alzheimer’s disease or dementia.
- Post-acute care patients have an average of 4.2 chronic conditions, and 21 percent of these patients have Alzheimer’s disease or dementia.
- Forty-two percent of patients admitted from the community qualify for both Medicare and Medicaid, compared to 24 percent of post-acute care patients.
- Home health aide services represented the majority of services provided in 11 percent of the episodes for people admitted from the community, whereas they represented 4 percent of the services for post-acute care patients.
Every year, one in five Medicare beneficiaries is hospitalized, and about 35 percent of hospitalized individuals are discharged to post-acute care (Gage et al., 2009). Among the individuals in the population discharged to post-acute care, 38 percent use more than one post-acute care provider. About one-quarter of those who go to home health care are readmitted to the hospital. Some of these cases are medically complex and some are not, Gage said; some readmissions are avoidable and some are not.
Patients follow different paths after acute care, Gage noted. About 23 percent of those who go into a formal service program go directly to home health care and receive all the care that they need there (Gage et al., 2009). More complex patterns involve transitions from the hospital to a skilled nursing facility and then to home health care. About 8 percent follow this pattern, she said. Tracking these diverse pathways demonstrates that “when we talk about a person’s services, it’s really an episode,” she said. “It isn’t just one unique service.”
Although some home health care patients have complex care needs, they probably do not need 24-hour nursing or they would have been discharged to a long-term care hospital, a rehabilitation hospital, or a skilled nursing facility, Gage said. On a scale from 1 to 100, home health patients have the highest mean self-care score, about 60, when they start home health care, she said, which is some 15 points higher than that for patients in skilled nursing facilities (Gage et al., 2012). Home health agencies also provide a large amount of therapy that is paid for by Medicare, but the level of care is much lower as compared to the level of therapy services provided to individuals in inpatient settings. Even so, Gage said, these therapy services may be keeping people mobile or able to carry out their activities of daily living (ADLs).
For outcomes, Gage’s research shows that home health care is able to achieve a 10-point gain (about 15 percent) in patients’ self-care functionality, which she calls “pretty impressive.” If similar analyses comparing gains in self-care ability for similar groups of patients are done, home health care patients again have larger improvements than patients in other settings (Gage et al., 2012). Some of the accomplishments of home health care arise from the fact that it treats a somewhat different patient population, Gage said. It is especially helpful for patients with musculoskeletal problems, for example, but does not provide an advantage for patients with nervous system problems or strokes.
Role of Home Health in the Changing Health Care Marketplace
The nurse case managers who do initial home health assessments are automatically doing case management of the type endorsed in the newer models of the organization of care, Gage said. As health care reform reemphasizes person centeredness and focuses on care coordination, outcomes, and cost-effectiveness, home health gains in importance. Clinicians now need to follow patients “past their front door and into the community,” Gage said, because now they are responsible for them 30, 60, or 90 days after hospital discharge, so what happens in the community is vitally important.
Home health agencies serve both the Medicare post-acute care and the LTSS populations. To the extent that hospitals are only just now learning about the need to take this longer-term, episode-based view, she said, they may not be as well integrated as desirable with the home health agencies in the community. In some locales, the home health agencies work closely with the agency on aging for that area, which can fill in additional pieces of the comprehensive care needs of a given patient. However, Gage said, there is a need for greater coordination, communication, and data standardization among service-providing agencies.
New legislation has directed the Centers for Medicare & Medicaid Services (CMS) to improve Medicare’s post-acute care services and the reporting on them.2 It will require home health agencies and other providers to submit data on quality measures, resource use, and standardized patient assessments. (It also includes a provision to study the effect of Medicare beneficiaries’ “socioeconomic status on quality, resource use, and other measures” and the impact of specified risk factors on such measures.) This will result in a more national approach to quality measurement and to thinking about patients “in a consistent way,” Gage said. Meanwhile, she said, there is consensus on how to measure key aspects of long-term care, like pressure ulcers, in ways that are reliable. Under the coordinated quality strategies of the U.S. Department of Health and Human Services, CMS is developing the infrastructure that will allow the electronic exchange of consensus-based quality measures that can be folded into bundled payments, for example. In many areas, she said, “standardized information is being moved into either the quality programs or the payment programs, or both.”
The strengths of home health that Gage believes will help shape its future are the proven programs that home health agencies often provide, including both home health care and hospice; the broad array of services that they provide, including nursing, therapy, social work, and aide services;
2 Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, Public Law 113-185, 113th Cong., 2nd sess. (October 6, 2014).
their placement in the community, where they know the local providers and often know the residents with more complex medical conditions; and the training of their staff in the coordination of services, such as medication reconciliation and social support, “which all of those different payment policy initiatives and quality metrics come back to: coordination and communication across the system.” Gage believes that home health care is an underutilized resource, particularly as the health care environment moves toward managing patients across a continuum of care.
Anne Montgomery, Altarum Institute
Kyle Allen, Riverside Health Systems
The ultimate goal for the continuum of care, Montgomery said, would be “to connect acute care, post-acute care, community agencies, and LTSS.” Although the U.S. Congress tried to establish such a program through the ACA, it was unsuccessful.3 Because of this failure, she believes that this arena may not be revisited legislatively for “quite a while.” Meanwhile, research and modeling that may reveal more viable approaches to making these connections “with existing programs, existing financing, and existing services” can continue.
Currently, because most health care policy is driven by budgetary and political considerations, policy skews strongly toward the status quo at a time when a lot of innovation and creativity is required, Montgomery said. At the Altarum Institute’s Center for Elder Care and Advanced Illness, Joanne Lynn has continued to develop a locally anchored, comprehensive model called MediCaring accountable care communities (ACCs), which would create some of the needed connections, she said. The model, which would deliver both health care and LTSS, is tailored to address the needs of the rapidly growing population needing a broad spectrum of services, primarily people over age 65 years with two or more problems with ADLs, those with cognitive impairment needing constant supervision, and the oldest old (those age 85 years and older) who are medically frail and do not have much reserve. According to Montgomery, features of ACCs include
3 The ACA included a Community Living Assistance Services and Supports (CLASS) Act, which would have instituted a voluntary, national, federally administered long-term care insurance program, but concerns about the program’s projected high costs and likely difficulties with implementation and sustainability caused it to be repealed in 2013.
- Comprehensive longitudinal care plans that cover all settings where a person receives care, including the home, and that are grounded in patient preferences for treatment and quality-of-life goals;
- More efficient and appropriate medical care tailored to the often unique needs of frail elders that are not addressed by the current “sick care and episodic” model and made more readily accessible at home, including 24-hour on-call arrangements;
- The full range of health, social, and supportive services, including assessment of the adequacy of housing;
- Use of core funding derived from shared savings in a community ACO structure modified to serve the frail elderly population (MediCaring ACCs); and
- Ongoing monitoring and improvement guided locally by a community board that comprises providers, professional managers, community agencies, and stakeholders (e.g., employers, because of the net negative impact of caregiving on employee productivity, and health and local leaders), which anchors the project in the community and works toward achieving sustainability.
Building such care plans and convincing policy makers of their value would enable the kinds of documents that health and social service providers could more easily follow on the basis of an understanding of “which services work, which are cost-effective, which are timely, and when they need to be adjusted,” Montgomery said. “The longitudinal care plan is sort of like the trunk of a tree, where all the treating providers are branches off of it.” Such plans are likely to be more administratively efficient as well, she said, because they would constitute a single plan and not the cumbersome and time-consuming multiple plans developed by different providers today in a “sick care/episodic care” delivery model. In aggregate, such care plans could aid with estimations of the need for services and workforce capacity in a given locale and whether too many or too few workers are available for the number of elders needing services.
Allen has been working on a project funded through the ACA’s Community-Based Care Transitions Program4 in two communities across the country and has been struck by the infrastructure built through the Administration on Aging Services in these communities. One of these projects worked with five local area agencies on aging as part of the Eastern Virginia Care Transitions Partnership, which covers about 7,500 square miles and both rural and urban areas. The partnership involves 11 hospitals in 5 different health care systems and is enrolling 900 people per month in a community-based care transitions model. In addition, Allen worked with
Altarum to design a Center for Medicare & Medicaid Innovation grant proposal tailored to four communities: Akron, Ohio; Milwaukie, Oregon; Queens, New York; and Williamsburg, Virginia.
These MediCaring ACCs, which are still in the development phase, would coordinate funding from multiple payers—Medicare and Medicaid, the Older Americans Act, state and local programs, and private sources—and in the process wring out current waste and inappropriate services and then reinvest and redeploy some of that funding for social services or to improve housing. The United States is quite different from the rest of the developed nations in the share of aggregate social services spending that goes to these health-related supports, which is very low, she said.
A package of waivers of existing Medicare rules would be necessary to pilot test the MediCaring ACC program, Montgomery said, among which are
- Waiving the Medicare rule limiting skilled nursing or therapy services delivery in the home to those who are homebound,
- Allowing nurse practitioners to authorize home health care or hospice services in states where that is permitted, and
- Allowing ACOs or other entities to enroll only frail elders and allow the geographic concentration of services.
The most important waiver is the last one, she said, which would allow shared savings across the bundle of services for this population.
Allen said that he is confident that this model could be funded through the projected savings that it will generate. A detailed financial model has been developed for four communities with extremely varied health care systems.
Massachusetts General Hospital
O’Malley harked back to the story related by James Martinez (see Chapter 1, Box 1-2), saying that individuals and their caregivers are the heart of the system. Swirling around them are all the other services that they need, he said, including health and wellness services, medical care, social services, LTSS, and home health care. Creating a new care model will depend on increasing the connections among them. “In health care, we’re a bunch of silos,” he said. “We only connect around the exchange of information around a patient, but the issue is what happens between the silos. It’s the white space.”
O’Malley reflected on previous presentations, noting that home health care alone offers a wide range of services, from hospital-in-the-home types of practices to the services of a person who can make home repairs. New standards and processes are critical to managing the array of services needed by people with multiple chronic conditions, disabilities, and frailty, he said. Innovative care models are having dramatic results in targeting high-risk patients, and O’Malley believes that these models are scalable. To bridge the gap between the current service delivery silos, O’Malley said that it will be necessary to add more social services to the medical model or more medical services to the social services model or develop ways to integrate them. Additional challenges include the need to make the transitions between sites of care or between different teams that provide care safe, close the open loops in referral management, and coordinate care across an entire episode (longitudinally), and engage providers so that they are working off the same patient care plan. Home health agencies could potentially be the manager or integrator of all these services, he said.
Although communication is vitally important in the creation of a coordinated system, home health and LTSS programs are unlikely to be able to afford costly electronic health records systems, O’Malley said. Numerous workshop participants pointed out that their home health agency used a data system different from the ones used by other providers in their networks. According to O’Malley, the creation of a shared information platform is therefore a significant challenge that will require the following:
- A compelling business case,
- The use of health information exchanges or other exchange mechanisms to connect with others,
- Low-cost ways to access the exchanges,
- Adoption of common data management standards to transmit data reliably,
- Standardized information that is meaningful to providers and others who can use it to monitor system performance, and
- Effective channels for two-way communication between service providers and patients and families.
O’Malley said that the information platform for home health needs to be inexpensive, easy to use, and reliable—“standardized and interoperable,” in the words of the Office of the National Coordinator for Health Information Technology (ONCHIT). ONCHIT has selected a standard for patient information exchange called the consolidated data architecture (CDA), and a library of reusable data templates that can be combined to form CDA documents exists. These documents can be of any size but use a specific syntax. “It’s just like Legos,” he said, noting that the different
pieces can come in many varieties but that they all work together and can be packaged in different ways.
As an example, O’Malley cited a project in Worcester, Massachusetts, in which the electronic record begins being built when the patient enters the emergency room and continues to be built through admission, is added to during the hospital stay, and upon discharge is sent to the skilled nursing facility (via low-cost, Web-based software called a surrogate electronic environment [SEE]). The information that the nursing facility collects for the Long-Term Care Minimum Data Set (MDS)5 is added to the CDA file and reconsolidated by SEE. Upon discharge from the nursing facility, an updated document is sent to home health and the primary care physician. What they learned in working on this project, O’Malley said, was not that they needed hundreds of different data sets, as was initially feared, but that by using the CDA system, they needed only five:
- The test or procedure report—what the clinician needs to get back when ordering a test;
- The test or procedure request—what the clinician needs to send when ordering the test;
- The shared care encounter summary—what the clinician needs to get back from a consultant (whether it is a specialist physician or the emergency department);
- The consultation request clinical summary—what the clinician needs to send to a consultant; and
- The transfer of care summary—what the institution needs to send when there is a permanent transfer of care (a discharge to any other site).
Every care site that receives a patient needs surprisingly similar information, O’Malley said. The data sets (described above) are nested, and many of the data elements in the smaller sets are reused in the larger sets. This is possible because the data elements are all interoperable and standardized.
The home health and longitudinal plans of care include many data elements that would already exist in these transitions of care data sets, plus some additional elements, O’Malley said. The plans of care are based on medical, surgical, nursing, behavioral, cognitive, and psychological issues, as well as information about function and the environment (e.g., housing,
5 The MDS “is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/ or Medicaid-certified long-term care facility. The MDS contains items that measure physical, psychological and psychosocial functioning” (CMS, 2012).
supports, transportation). These can be mapped to the data sets. Specific medical conditions or medication-based expansions can be included. “If you can exchange not so much the care plan but the interoperable, critical parts of a plan—concerns, interventions, goals, and assigned team members—the receivers can reuse those components in their own care planning process,” he said. According to O’Malley, the components of a CDA document can include the following, among many other elements:
- Patient history and physical notes,
- Progress notes,
- Diagnostic imaging reports,
- Operative notes,
- Procedure notes,
- A discharge summary,
- A continuity-of-care document,
- Consultation notes,
- Referral notes,
- A transfer summary, and
- A care plan.
Each of these sections can be broken down into multiple fields of information.
Again, he said, building this will require shared mechanisms to exchange health information and the acquisition and use of low-cost software. Once the CDAs are created, they can be used for additional purposes, such as reporting on quality and management of population health. This model represents a solution to the challenge of sharing essential health information across different sites to facilitate the level of care coordination needed by patients with complex medical conditions, O’Malley said.
If home health agencies participate in this shared information exchange between health care and community-based service providers, it provides them with the opportunity to play a number of new roles, in addition to the role of service provider, O’Malley said. “This gets home care away from merely selling the commodity of home care visits.” Home health agencies can become aggregators, integrators, managers, and guarantors of the range of services needed by individuals with complex health care needs. In so doing, he said, they can sell value, which comes with the integration of services and with the establishment of these services as reliable, consistent, and scalable. “The reason home care can do this,” O’Malley said, “is that no one else in the health sector does—or can do—what home care does, by bringing services to the individual, not the other way around, by providing services in geographically dispersed areas, not a fixed location, and
by being the bridge between traditional health care and community-based service providers.”
A brief open discussion followed the panelists’ presentations. Workshop participants were able to give comments and ask questions of the panelists. The following sections summarize the discussion session.
Montgomery noted that the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 20146 will require reporting on standardized measures that will give a much closer look at patient function and a broader view of service provider capabilities, as well as greater accountability across post-acute care settings.7 Gage said that the act’s quality metrics are all basic information that home health agencies already monitor and collect.
Even with more standardized post-acute care metrics, coordination of these services with hospitals is likely to continue to pose challenges. Peter Boling, Virginia Commonwealth University, related a story about one of his patients and said that even having an electronic health record that notes the identity of a patient’s primary care physician does not prevent assignment to another doctor for follow-up if the patient ends up in the hospital of a different health care system. Patients need a greater say in which hospital and system that they are taken to, O’Malley said. In addition, basic rules of the road will have to be worked out between health care providers and shared savings plans, which are accountable for the full care of a patient, whether that is delivered in network or by others, he said. Obviously, plans would prefer to have their patients under their supervision and care. Allen added that patient education in advance about the importance of staying in the correct managed care model (or, in his experience, Program of All-Inclusive Care for the Elderly [PACE]) to avoid out-of-pocket costs may be a partial approach. In addition, O’Malley said, the emergency medical technicians who take the patient to the out-of-network hospital also should be part of
6 Improving Medicare Post Acute Care Transformation Act of 2014, Public Law 113-185, 113th Cong., 2nd sess. (October 6, 2014).
7 According to Montgomery, under the IMPACT Act, the new quality measures that all post-acute care providers will be required to report are “functional status, cognitive function, and special services; treatments and interventions, such as the need for ventilator use, dialysis, chemotherapy, central line placement, and total parenteral nutrition; medical conditions and comorbidities, such as diabetes, congestive heart failure, and pressure ulcers; impairments such as incontinence and impaired ability to hear, see, or swallow; and other categories deemed necessary and appropriate by the Secretary.”
the information exchange. They should be able to download all the information that they need about the patient, including hospital preference, he said. Part of the organization around MediCaring ACCs involves bringing the emergency medical service providers to the table, Allen noted. Just by working more closely together locally, improvements in how services are linked can be made. On the West Coast, an increasing number of emergency services programs are actually functioning like case managers, because they know the patients who return often to the hospitals, Gage said. “They know the home; they know where the patient needs to go.”